Summary Report for FSPSAs Initiated During the Report Period                                             Center: 07

This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.

FSPSAs starting between: 10-01-12 and 12-31-12                  Date of Report: 02-16-13                  Page: 1

    Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients


Services  Cpt Code                                       Number of   Number of       Total Units    Total Cost of          Avg Fee
                                                         Children    Records         Authorized     Auth Services       Per Unit Auth



Service Coordination, Class # 01
 SCONLY-SCONLY    SERVICE COORDINATION ONLY                    1          1            3.000000           $0.0000            $0.0000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      1          1            3.000000           $0.0000            $0.0000


Screening, Eval, and Assessment, Class # 02
 OCTH  -97003     OT EVAL BY LICENSED OT, INITIAL              1          1            0.083333           $4.0400           $48.4800
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      1          1            0.083333           $4.0400           $48.4800


EI Services, Class # 03
 CONIF -CONIF     CONSULT ITDS, FACE TO FACE                   3          4           30.304762        $1515.2500           $50.0000
 CONOF -CONOF     CONSULT, OT, FACE TO FACE                    2          2           19.714286         $985.7200           $50.0000
 CONPF -CONPF     CONSULT, PT, FACE TO FACE                    1          1           13.000000         $650.0000           $50.0000
 CONSF -CONSF     CONSULT, SLP, FACE TO FACE                   1          1           13.000000         $650.0000           $50.0000
 EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF            11         12          125.666667        $6283.3400           $50.0000
 SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP          2          2           16.285714        $1105.4700           $67.8800
 TRAV  -TRAV      PROVIDER TRAVEL TO NATURAL ENVIRONM         10         13         6466.571429        $3233.2900            $0.5000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                     15         35         6684.542858       $14423.0500            $2.1600


-------------------------------------------------------------------------------------------------------------------------------------
Total                                                                    37         6687.626191       $14427.0900            $2.1600
-------------------------------------------------------------------------------------------------------------------------------------

Number of Children (Unduplicated) With at Least One Authorization  16